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Thrombolysis and Thrombectomy
Brandt C. Wible, MD; T. Gregory Walker, MD, FSIR
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KEY FACTS

  • Terminology

    • Preprocedure

      • Procedure

        • Outcomes

          TERMINOLOGY

          • Definitions

            • Thrombolysis: Minimally invasive method for clearing/dissolving intravascular thrombus
              • IV thrombolysis delivers systemic dose of medication designed to promote fibrinolysis
                • Most commonly used form of thrombolysis
                  • Tissue plasminogen activator (tPA) most frequently used thrombolytic drug
              • Direct intravascular thrombolysis requires placement of catheter/device into thrombosed vessel
                • May place either intraarterially or intravenously
                  • Localized treatment of thrombosed target vessel
            • Thrombectomy: Removal of acute or chronic thrombus without use of thrombolytic medications
            • Catheter-directed thrombolysis (CDT): Infusion of thrombolytic agent via percutaneously placed catheter
              • Delivers concentrated dose to thrombosed vessel
              • May be intraarterial or IV
            • Mechanical thrombectomy (MT): Fragmentation/aspiration/coring of thrombus using intravascular medical device
              • Mechanism of action dependent on device: Macerates clot into macro-/microscopic debris, or aspirates whole thrombus via large-bore catheter
              • Rapid, single session treatment
              • May be appropriate for patients with contraindication to thrombolytics
            • Pharmacomechanical thrombolysis (PCDT): Use of combined mechanical device and thrombolytic agent
              • Increases thrombus surface area in contact with thrombolytics

          PREPROCEDURE

          • Indications

            • Contraindications

              • Preprocedure Imaging

                • Getting Started

                  PROCEDURE

                  • Procedure Steps

                    • Findings and Reporting

                      • Alternative Procedures/Therapies

                        POST PROCEDURE

                        • Things to Do

                          OUTCOMES

                          • Complications

                            • Expected Outcomes

                              Selected References

                              1. Buckley JR et al: In-hospital mortality and related outcomes for elevated risk acute pulmonary embolism treated with mechanical thrombectomy versus routine care. J Intensive Care Med. 37(7):877-82, 2022
                              2. Ahmed O et al: Meta-analysis of the usefulness of inferior vena cava filters in massive and submassive pulmonary embolism. Am J Cardiol. 128:54-9, 2020
                              3. Pei DT et al: Meta-analysis of catheter directed ultrasound-assisted thrombolysis in pulmonary embolism. Am J Cardiol. 124(9):1470-7, 2019
                              4. Wible BC et al: Safety and efficacy of acute pulmonary embolism treated via large-bore aspiration mechanical thrombectomy using the Inari FlowTriever Device. J Vasc Interv Radiol. 30(9):1370-5, 2019
                              5. Fleck D et al: Catheter-directed thrombolysis of deep vein thrombosis: literature review and practice considerations. Cardiovasc Diagn Ther. 7(Suppl 3):S228-37, 2017
                              6. Watson L et al: Thrombolysis for acute deep vein thrombosis. Cochrane Database Syst Rev. 11:CD002783, 2016
                              7. Comerota AJ: Thrombolysis for deep venous thrombosis. J Vasc Surg. 55(2):607-11, 2012
                              8. Manninen H et al: Catheter-directed thrombolysis of proximal lower extremity deep vein thrombosis: a prospective trial with venographic and clinical follow-up. Eur J Radiol. 81(6):1197-202, 2012
                              9. Karnabatidis D et al: Quality improvement guidelines for percutaneous catheter-directed intra-arterial thrombolysis and mechanical thrombectomy for acute lower-limb ischemia. Cardiovasc Intervent Radiol. 34(6):1123-36, 2011
                              10. Kühn JP et al: Intraarterial recombinant tissue plasminogen activator thrombolysis of acute and semiacute lower limb arterial occlusion: quality assurance, complication management, and 12-month follow-up reinterventions. AJR Am J Roentgenol. 196(5):1189-93, 2011
                              11. Popuri RK et al: The role of thrombolysis in the clinical management of deep vein thrombosis. Arterioscler Thromb Vasc Biol. 31(3):479-84, 2011
                              12. Schrijver AM et al: Dutch randomized trial comparing standard catheter-directed thrombolysis versus ultrasound-accelerated thrombolysis for thromboembolic infrainguinal disease (DUET): design and rationale. Trials. 12:20, 2011
                              13. Wicky ST: Acute deep vein thrombosis and thrombolysis. Tech Vasc Interv Radiol. 12(2):148-53, 2009
                              14. Semba CP et al: Thrombolysis for lower extremity deep venous thrombosis. Tech Vasc Interv Radiol. 7(2):68-78, 2004
                              15. Semba CP et al: Alteplase as an alternative to urokinase. Advisory Panel on Catheter-Directed Thrombolytic Therapy. J Vasc Interv Radiol. 11(3):279-87, 2000
                              Related Anatomy
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                              Related Differential Diagnoses
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                              References
                              Tables

                              Tables

                              KEY FACTS

                              • Terminology

                                • Preprocedure

                                  • Procedure

                                    • Outcomes

                                      TERMINOLOGY

                                      • Definitions

                                        • Thrombolysis: Minimally invasive method for clearing/dissolving intravascular thrombus
                                          • IV thrombolysis delivers systemic dose of medication designed to promote fibrinolysis
                                            • Most commonly used form of thrombolysis
                                              • Tissue plasminogen activator (tPA) most frequently used thrombolytic drug
                                          • Direct intravascular thrombolysis requires placement of catheter/device into thrombosed vessel
                                            • May place either intraarterially or intravenously
                                              • Localized treatment of thrombosed target vessel
                                        • Thrombectomy: Removal of acute or chronic thrombus without use of thrombolytic medications
                                        • Catheter-directed thrombolysis (CDT): Infusion of thrombolytic agent via percutaneously placed catheter
                                          • Delivers concentrated dose to thrombosed vessel
                                          • May be intraarterial or IV
                                        • Mechanical thrombectomy (MT): Fragmentation/aspiration/coring of thrombus using intravascular medical device
                                          • Mechanism of action dependent on device: Macerates clot into macro-/microscopic debris, or aspirates whole thrombus via large-bore catheter
                                          • Rapid, single session treatment
                                          • May be appropriate for patients with contraindication to thrombolytics
                                        • Pharmacomechanical thrombolysis (PCDT): Use of combined mechanical device and thrombolytic agent
                                          • Increases thrombus surface area in contact with thrombolytics

                                      PREPROCEDURE

                                      • Indications

                                        • Contraindications

                                          • Preprocedure Imaging

                                            • Getting Started

                                              PROCEDURE

                                              • Procedure Steps

                                                • Findings and Reporting

                                                  • Alternative Procedures/Therapies

                                                    POST PROCEDURE

                                                    • Things to Do

                                                      OUTCOMES

                                                      • Complications

                                                        • Expected Outcomes

                                                          Selected References

                                                          1. Buckley JR et al: In-hospital mortality and related outcomes for elevated risk acute pulmonary embolism treated with mechanical thrombectomy versus routine care. J Intensive Care Med. 37(7):877-82, 2022
                                                          2. Ahmed O et al: Meta-analysis of the usefulness of inferior vena cava filters in massive and submassive pulmonary embolism. Am J Cardiol. 128:54-9, 2020
                                                          3. Pei DT et al: Meta-analysis of catheter directed ultrasound-assisted thrombolysis in pulmonary embolism. Am J Cardiol. 124(9):1470-7, 2019
                                                          4. Wible BC et al: Safety and efficacy of acute pulmonary embolism treated via large-bore aspiration mechanical thrombectomy using the Inari FlowTriever Device. J Vasc Interv Radiol. 30(9):1370-5, 2019
                                                          5. Fleck D et al: Catheter-directed thrombolysis of deep vein thrombosis: literature review and practice considerations. Cardiovasc Diagn Ther. 7(Suppl 3):S228-37, 2017
                                                          6. Watson L et al: Thrombolysis for acute deep vein thrombosis. Cochrane Database Syst Rev. 11:CD002783, 2016
                                                          7. Comerota AJ: Thrombolysis for deep venous thrombosis. J Vasc Surg. 55(2):607-11, 2012
                                                          8. Manninen H et al: Catheter-directed thrombolysis of proximal lower extremity deep vein thrombosis: a prospective trial with venographic and clinical follow-up. Eur J Radiol. 81(6):1197-202, 2012
                                                          9. Karnabatidis D et al: Quality improvement guidelines for percutaneous catheter-directed intra-arterial thrombolysis and mechanical thrombectomy for acute lower-limb ischemia. Cardiovasc Intervent Radiol. 34(6):1123-36, 2011
                                                          10. Kühn JP et al: Intraarterial recombinant tissue plasminogen activator thrombolysis of acute and semiacute lower limb arterial occlusion: quality assurance, complication management, and 12-month follow-up reinterventions. AJR Am J Roentgenol. 196(5):1189-93, 2011
                                                          11. Popuri RK et al: The role of thrombolysis in the clinical management of deep vein thrombosis. Arterioscler Thromb Vasc Biol. 31(3):479-84, 2011
                                                          12. Schrijver AM et al: Dutch randomized trial comparing standard catheter-directed thrombolysis versus ultrasound-accelerated thrombolysis for thromboembolic infrainguinal disease (DUET): design and rationale. Trials. 12:20, 2011
                                                          13. Wicky ST: Acute deep vein thrombosis and thrombolysis. Tech Vasc Interv Radiol. 12(2):148-53, 2009
                                                          14. Semba CP et al: Thrombolysis for lower extremity deep venous thrombosis. Tech Vasc Interv Radiol. 7(2):68-78, 2004
                                                          15. Semba CP et al: Alteplase as an alternative to urokinase. Advisory Panel on Catheter-Directed Thrombolytic Therapy. J Vasc Interv Radiol. 11(3):279-87, 2000